Harmony Cedar Rapids

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 53.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 96 beds and averages 78.1 residents a day — about 81% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.38 hrs/resident/day on weekends vs 3.83 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 74% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · J2023-08-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews and policy review, the facility failed to ensure appropriate care and treatment to prevent urinary tract infections (UTI) leading to a resident suffering from septic shock and deep tissue pressure injury to the urethral meatus (tip of the penis) for 1 of 3 residents reviewed for catheter care (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 28, 2023 on July 26, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. Resident #1 resides in the center, head to toe assessment was completed and pain evaluation with interventions. b. Facility wide base line audit completed on 7/26/23 to identify residents with indwelling catheter or suprapubic catheter. c. Skin assessment completed on all patients identified on base line audit who have an indwelling/suprapubic catheter; and a whle house skin sweep completed by…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-08-02 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to implement their infection control policy to ensure MRSA (a contagious staph bacteria infection) was contained. Staff interviews revealed Resident #1 had a suprapubic catheter leaking urine onto clothes and sheets; staff were unaware Resident #1 was positive for MRSA due to a Nurse not reporting Lab Results and the facility did not provide personal protective equipment for staff use for 4 days. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 21, 2023 on July 26, 2023 at 4:30 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. Resident #1, who resides in the facility, was assessed and placed in isolation to include remaining in room for meals while on isolation. b. A facility wide audit was completed on 7/27/23 to identify residents currently on antibiotics for treatment of UTI's (Urinary…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on clinical record review, staff and resident interviews, manufacturer's recommendation and facility policy review the facility failed to transfer one of four residents reviewed in a safe manner (Resident #1). On 11/13/25, Resident #1 fell backwards from the stand lift, reported pain 9 out of 10 to the left hip, was sent to the hospital, and had a femur fracture which required surgical repair. The facility reported a census of 83 residents.The facility corrected the deficient practice per past noncompliance on 11/28/25 through the following actions:*Nursing staff re-educated on the proper use of mechanical lifts*Facility wide audit of mechanical lift equipement.*Nursing staff completed a skills check-off for standing lift and full body mechanical lift.*Audits of resident transfers using mechanical lifts.*Nursing staff interview related to refusal of safety straps and use for Resident #1.*Resident interviews regarding use of stand lift.Findings include:The Minimum Data Set (MDS) assessment for Resident #1 dated 10/15/2025 listed diagnoses of multiple sclerosis (MS),…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-08-02 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, observation and record review, the facility failed to manage pain for 1 of 3 residents reviewed for dressing changes (Resident #1). Resident #1 stated he had experienced pain during daily dressing changes for 6 weeks. The facility reported a census of 72 residents. The MDS dated [DATE] revealed Resident #1 had a diagnosis of renal insufficiency, obstructive uropathy, urinary tract infection (UTI) septicemia (blood poisoning by bacteria) and required extensive assistance of 1 person for personal hygiene. Resident #1 had a brief Interview for mental status (BMI) score of 12 indicating a slight impairment of cognition. The MDS identified Resident #1 had a clear comprehension and ability to express ideas and wants. Care Plan dated 6/15/23 for Resident #1 revealed an open area to distal penis related to the Foley (indwelling) catheter tubing and directed staff to apply wound treatment as ordered by the physician, assess for pain, administer pain medication as ordered by the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-21 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility policy review, the facility failed to maintain infection control practices to help prevent the development and transmission of communicable diseases and infections during glucometer use for two residents reviewed for medication administration. (Resident #2, #3). The facility reported a census of 76 residents.Findings include:1.Resident #2's admission Record for admission date 3/12/26 identified the resident had diagnoses including Diabetes Mellitus type 2, congestive heart failure, and dementia. Resident #2's Physician Orders included an order for staff to check the resident's blood sugar by finger sticks four times a day, initiated 3/12/2026. On 4/9/2026, the resident's Care Plan directed staff to monitor his blood sugar as ordered. Observation on 4/21/2026 at 12:05 p.m. revealed Staff A, RN (Registered Nurse), retrieved the necessary items to check the resident's blood sugar. Staff A indicated it was the first time she worked at the facility. She collected…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-03 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and facility policy review the facility failed to respond to call lights in a timely manner for 3 of 3 residents reviewed (Residents#12,#14,#27). The facility reported a census of 78 residents. 1.The Brief Interview for Mental Status (BIMS) assessment for R#12 dated 2/25/26 revealed the resident scored 15 out of 15, which indicated intact cognition. On 2/24/26 at 9:04 AM Resident #12 relayed the call light response had taken up to an hour, used either the phone or clock for timing the response. 2. The BIMS assessment for Resident #14 dated 2/3/26 revealed the resident scored 9 out of 15, which indicated moderately impaired cognition. On 2/24/26 at 9:03 AM Resident #14 relayed the call light response varied, quick at times or up to an hour, was not specific to a shift, varied. Resident #14 relayed timed the responses with the phone or clock. 3. The BIMS assessment for Resident #27 dated 2/16/26 revealed the resident scored 14 out of 15, which indicated intact cognition. On 2/23/26…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, family, and staff interviews, and facility assessment review, the facility failed to ensure residents had a safe, homelike environment for three of four residents reviewed (#10, #27, #38).The facility reported a census of 78 residents.Findings include: 1. Resident #38's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #38 required partial to moderate assistance with toileting and frequently incontinent of urine. On 2/23/26 at 11:50 AM, Resident #38's room was observed. The resident was asleep in their wheelchair. Soiled linens and bedding were observed on the resident's bed. The sheets had a dried brown substance on them. There was a distinct foul smell throughout the room. On 2/23/26 at 1:32 PM, the soiled linens remained on Resident #38's bed. The bed pad and soiled sheets were observed in the same state as earlier in the day. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-03 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to code dental concerns appropriately on the quarterly and annual Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 78 residents. Findings include:Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed diagnoses of Traumatic Spinal Cord Dysfunction, paraplegia, diabetes and renal disease. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS lacked any coding in the dental section for mouth, facial pain or discomfort. Review of Resident #10's Annual Minimum Data Set (MDS) assessment dated [DATE] again lacked any coding in the dental section for mouth, facial pain or discomfort. A Progress Note dated 8/28/25 revealed Resident #10 said My mouth hurts, had history of cracked teeth, presented with dental pain, caries noted on the left upper teeth, and initiated antibiotic therapy due to concern or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the resident interview, staff interviews, clinical record review, and dialysis contract/agreements the facility failed to direct staff of transfer requirement for dialysis appointments on the resident's care plan (Resident #4), and failed to address a resident's teeth pain and the related infections on the care plan (Resident #10) for two of twenty-one residents reviewed for care plans. The facility reported a census of 78 residents.Findings included:1.Resident #4, Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis. The Care Plan initiated 4/17/25 documented Resident #4 required dialysis on Monday, Wednesday and Friday. The Care Plan did not direct staff to ensure the sling is required to be sent to enable transfer to dialysis chair. On 2/23/2026 at 11:13 AM Resident #4 relayed was not able to get dialysis today because the staff did not put the transfer sling under me on the chair that is required by dialysis. Resident #4…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-03 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview and policy review the facility failed to follow professional standards when returned medications refused back to the medication cart to administer at a later time for 1 of 5 residents observed during medication administration (Resident #13), and failed to provide medications by the proper route for 1 of 1 reviewed for tube feeding (Resident #1). The facility reported a census of 78 residents. Findings include: 1.Review of Resident #13's Minimum Data Set (MDS) dated [DATE] documented took medications which included antipsychotic, antidepressant and anticonvulsants. The MDS further documented the resident had diagnosis included high blood pressure, anxiety, depression and seizure disorder. The February 2026 Medication Administration Record (MAR) documented Resident #13 medications for the AM included: a. amlodipine (antihypertensive)b. aripiprazole (for depression) c. atenolol (antihypertensive)d. bisacodyl (for constipation)e. clopidogrel (related to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and clinical record review the facility failed to ensure safe transport of resident in a wheelchair for 1 of 5 residents reviewed for accidents (Resident #60). The facility reported a census of 78 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #60 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per this assessment the resident utilized a wheelchair for mobility and had the ability to wheel at least 150 feet in a corridor or similar independently.Review of the Care Plan intervention dated 2/27/24 revealed Resident #60 was an assist of two staff for transferring, and was non ambulatory. On 2/25/26 at 10:45 AM, Staff G, Activities Assistant pushed Resident #60 in their wheelchair while the wheelchair did not have foot pedals applied. Staff G approached the resident from behind, advised the resident they would push them to the activity area and swiftly pushed the resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the resident interview, staff interviews, and record review the facility failed to ensure a resident had a transfer sling before leaving for a dialysis appointment, which caused missed dialysis treatment for 1 of 3 residents reviewed for dialysis (Resident #4). The facility reported a census of 78 residents.Findings include: Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis.The Care Plan focus area for dialysis, dated 5/8/25, documented Resident #4 required dialysis related to ESRD, and the intervention dated 5/8/25 revealed resident received dialysis on Monday, Wednesday and Friday. On 2/23/26 at 11:13 AM, Resident #4 relayed was not able to get dialysis today because the staff did not put the transfer sling under the resident on the chair that is required by dialysis, and the dialysis clinic staff said the resident had to go back to the facility. Resident #4 relayed there would not be enough time…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility policy the facility failed to ensure a medication error rate of less than 5% when two errors were observed from thirty-one opportunities for 1 of 5 residents observed during medication observations (Resident #9). This resulted in a medication error rate of 6.45%. The facility reported a census of 78 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] documented the resident took medications which included high risk medications, hypoglycemic for diabetes control and diuretics. The MDS further documented the resident had diagnoses which included heart disease and diabetes. Beginning observation on 2/25/26 at 9:27 AM Staff A, Certified Medication Aide (CMA) placed in a medication cup the following medications ordered for Resident #9.One of each of the following oral medications for Resident #91. methocarbamol , 500 milligrams (mg) 2. primidone, 50 mg3. furosemide, 40 mg4. atenolol, 50 mg5. jardiance, 10 mg6. potassium, 10…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0791 — failed to provide routine dental services — isolated
  Provide or obtain dental services for each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interview, and policy review the facility failed to ensure ongoing coordination of dental services for 2 of 2 residents reviewed for dental services (Resident #10, # 76). The facility reported a census of 78 residents. Findings include: 1.Review of Resident #10's Minimum Data Set (MDS) annual assessment dated [DATE] listed diagnoses of Traumatic Spinal Cord Dysfunction, paraplegia, diabetes and renal disease. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS did not code for dental, mouth or pain discomfort. The Care Plan focus for Resident #10 initiated 6/16/25 documented had complaints of pain related to obesity, gout, spinal cord injury, substance abuse history, kidney disease and diverticulitis, and had acute pain due to abdominal distention and recent diagnosis of stercoral colitis (inflamed bowel). The Care Plan did not address Resident #10 repeated complaints of teeth pain, which included…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$10,509 in federal fines across 1 penalty.

• $10,509 — penalty dated 2025-12-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $379K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IA